Hyperkalemia & Hypokalemia Nursing Care Plans

Potassium is the electrolyte that stops hearts. Both directions are emergencies: high potassium drives the heart toward fibrillation and arrest, low potassium sets off lethal atrial and ventricular dysrhythmias and potentiates digoxin. Watch the monitor, watch urine output before you ever push potassium, and never give a concentrated bolus.

Potassium (K) Imbalances

Potassium is the major cation in intracellular fluid. It regulates ECF osmolarity by exchanging with sodium across the sodium-potassium pump, holds the transmembrane electrical potential between ICF and ECF, and drives normal neuromuscular contraction.

Normal serum potassium runs 3.5 to 5.0 mEq/L.

• Hyperkalemia: serum potassium above 5.0 mEq/L.
• Hypokalemia: serum potassium below 3.5 mEq/L.

Hyperkalemia: Risk for Electrolyte Imbalance

High potassium shows up in renal disease (the kidneys cannot excrete it), after massive transfusion of banked blood (stored cells release potassium), and as a drug or chemotherapy effect.

May be related to

• Renal disease
• Treatment-related side effects such as cytotoxic drugs, NSAIDs, diuretics, potassium-containing medications, and massive transfusion with banked blood

Desired Outcomes

The client will display heart rate, blood pressure, and laboratory results within normal limits, with no paresthesia, muscle weakness, or cognitive impairment.

Assessment

The priority is catching life-threatening cardiac dysrhythmias and finding the underlying cause.

Monitor heart rate and rhythm. Potassium excess depresses myocardial conduction. Bradycardia can progress to fibrillation and arrest.

Monitor respiratory rate and depth, encourage deep breathing and coughing, and elevate the head of the bed. Clients may hypoventilate and retain carbon dioxide, causing respiratory acidosis. Muscle weakness can reach the respiratory muscles.

Assess level of consciousness and neuromuscular function (sensation, strength, movement). The client is usually alert, but paresthesia, weakness, and flaccid paralysis can occur.

Monitor urine output. Failing kidneys retain potassium. Potassium is contraindicated with oliguria or anuria.

Identify the at-risk client or cause (excessive intake or decreased excretion). Early identification heads off complications.

Monitor serum potassium and arterial blood gases. Guides therapy and tracks effectiveness.

Interventions

The aim is to drop serum potassium and prevent dysrhythmias through medication, diet, and monitoring.

Encourage rest periods and assist with daily activities. Muscle weakness lowers activity tolerance.

Tell the client to notify future caregivers about chronic conditions that drive hyperkalemia, such as oliguric renal failure. Helps prevent recurrences.

Teach and assist with range-of-motion exercises as tolerated. Improves muscle tone and reduces cramps and pain.

Encourage carbohydrates, fats, and low-potassium foods (pineapple, plums, strawberries, carrots, cauliflower, corn, whole grains). Cuts exogenous potassium and prevents tissue breakdown that releases cellular potassium.

Identify and discontinue high-potassium foods (beans, dark leafy greens, potatoes, squash, yogurt, fish, avocados, mushrooms, bananas). Lowers potassium and prevents recurrence.

Review the drug regimen for potassium-containing or potassium-sparing agents (spironolactone [Aldactone], hydrochlorothiazide [Maxzide], amiloride [Midamor], penicillin G). May require alternate drugs or dosing changes with regular potassium checks.

Administer medications as indicated:

• Loop diuretics such as furosemide (Lasix) promote renal potassium clearance.
• Beta-adrenergic agonist such as albuterol (Proventil) by nebulizer drives potassium into cells, useful in clients on hemodialysis.
• Calcium gluconate or calcium chloride, a temporary stopgap, antagonizes potassium's depressant effect on the heart and stabilizes the myocardium.
• IV glucose with insulin and sodium bicarbonate moves potassium into cells short-term, lowering toxic serum levels.
• Sodium polystyrene sulfonate (Kayexalate, SPS suspension) by NG tube, orally, or rectally exchanges potassium for sodium or calcium in the GI tract; sorbitol speeds evacuation.

Transfuse fresh blood or washed RBCs when transfusion is indicated. Fresh blood holds less potassium than banked blood, where aging RBCs break down and release it.

Infuse potassium-based solutions slowly. Prevents a concentrated bolus and gives the kidneys time to clear excess.

Supply balanced electrolyte IV solutions as directed. Lactated Ringer's matches extracellular fluid. Isotonic saline (0.9% sodium chloride) can cause hypernatremia over time, and sodium-free solutions (D5W) risk hyponatremia.

Irrigate nasogastric tubes with isotonic saline, not plain water. Plain water pulls electrolytes from mucosal tissue into the stomach, where suction removes them.

Prepare for and assist with dialysis. The definitive treatment when conservative measures fail or are contraindicated, as in severe heart failure or end-stage renal disease with serious ECG changes.

Hypokalemia: Risk for Electrolyte Imbalance

Low potassium follows diarrhea and vomiting, diabetic acidosis, renal failure, a high-sodium diet, profuse sweating, and treatment side effects. The body loses potassium, takes in too little, or shifts it into the cells.

May be related to

• Diarrhea, vomiting
• Diabetic acidosis, renal failure
• High-sodium diet, starvation
• Profuse sweating
• Treatment-related side effects such as diuretics, TPN, and some antibiotics

Desired Outcomes

The client will display heart rhythm and laboratory results within normal limits, with no paresthesia, muscle weakness, or cognitive impairment.

Assessment

Monitor respiratory rate, depth, and effort, encourage deep breathing and coughing, and reposition frequently. Respiratory muscle weakness can progress to paralysis and arrest.

Monitor heart rate and rhythm. Hypokalemia disrupts conduction and contractility. Watch for tachycardia and life-threatening atrial and ventricular dysrhythmias: AV blocks, AV dissociation, ventricular tachycardia, and PVCs.

Note signs of metabolic alkalosis (tachycardia, dysrhythmias, hypoventilation, tetany, mentation changes). These usually accompany hypokalemia.

Monitor level of consciousness and neuromuscular function (movement, strength, sensation). Tetany, paresthesia, apathy, drowsiness, irritability, and coma can occur.

Track gastric, urinary, and wound losses accurately. Guides fluid and potassium replacement. Give potassium only with good urinary flow, since the kidneys are the main route of elimination; with poor flow, potassium builds up and causes arrhythmias, weakness, and paralysis. Check urine output before giving potassium and monitor levels during and after.

Watch for absent or changed bowel sounds. Paralytic ileus follows gastric losses from vomiting, suction, or diarrhea.

Watch for digoxin toxicity (blurred vision, vomiting, nausea, increasing atrial dysrhythmias, heart block). Hypokalemia enhances digoxin and slows cardiac conduction.

Monitor labs:

• Arterial blood gases. Correcting alkalosis raises serum potassium and lowers replacement needs; correcting acidosis drives potassium into cells, dropping serum levels and raising needs.
• Serum potassium. Check often during replacement, especially with insufficient renal function.

Interventions

Discuss preventable causes (nutritional choices, proper laxative use). Dietary control is more palatable than oral replacement and prevents recurrence.

Encourage high-potassium foods (oranges, bananas, tomatoes, coffee, red meat, dried fruit) and potassium chloride salt substitutes for clients on long-term diuretics. Diet can replace and maintain potassium when oral intake is allowed. Dietary replacement of 40 to 60 mEq/L/day is usually enough without abnormal losses.

Control the rate of IV potassium with a microdrop set or infusion pump, watch for side effects, and apply an ice pack as indicated. Controlled delivery prevents a bolus effect. When the central vein is unavailable and slowing the rate is not possible, an ice pack at the site eases the burning.

Review the regimen for potassium-wasting drugs (amphotericin B [Fungizone], IV catecholamines, carbenicillin [Geocillin], furosemide [Lasix], gentamicin [Garamycin], hydrochlorothiazide). When potassium-sparing diuretics (Aldactone, Midamor) cannot be substituted, or with high-dose sodium drugs like carbenicillin, monitor and replace potassium closely.

Administer potassium orally or IV. Corrects deficiencies when medication, therapy, and diet changes are inadequate. IV potassium is lifesaving but, given incorrectly or in excess, causes cardiac arrest, arrhythmias, and tissue damage. Monitor levels closely and follow established guidelines.